BCFS001304-UA-Combs-DownSyndrome [Screening Form] -

Screening Form

Please complete the screening form below and our team will be in touch. Thank you!

Displayed

Parent's First Name

Displayed

Parent's Last Name

Parent's Phone Number

Parent's Email Address

Displayed

Parent's Date of Birth

Displayed

What city do you live in?

Displayed

What state do you live in?

Child's First Name

Child's Last Name

Displayed

Child's Gender

Male

Female

Other

Child's Date of Birth

Displayed

Select all of the following that best describes your child:

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino, or Spanish origin

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Has your child been diagnosed with Down syndrome?

Yes, trisomy 21

Yes, Mosaic Down syndrome

Yes, Translocation Down syndrome

No, not diagnosed with Down syndrome.

Is your child currently using Positive Airway Pressure (PAP) therapy?

Yes

No

Is your child able to discontinue its use?

Yes

No

How many weeks into pregnancy was your child born?

Does your child have a history of seizures?

Yes

No

Do you have untreated or inadequately treated hypothyroidism?

Yes

No

Does your child have untreated depression?

Yes

No

Does your child have a history of liver disease?

Yes

No

Would you be able to travel to Tucson, Arizona if travel expenses were reimbursed up to $1,000 per visit?

Yes

No

You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.